Homeowners Insurance Application 1. Insured Information Insureds Name: * First Name Last Name Date of Birth: * MM DD YYYY SSN: Employment Status: * Employed Self Employed Retired Other Occupation: Spouse Name: First Name Last Name Spouse Date of Birth: MM DD YYYY Spouse SSN: Spouse Employment Status: Employed Self-Employed Retired Other Spouse Occupation: Mailing Address: * Address 1 Address 2 City State/Province Zip/Postal Code Country Email Primary Phone: * Select: Mobile Home Business Spouse Other Phone * (###) ### #### 2. Location Information Is the Location Address the Same as the Mailing Address? * (If YES, Please Skip to "Property Information") Yes - Skip No - Continue Location Address: Address 1 Address 2 City State/Province Zip/Postal Code Country 3. Property Information Location Use: * Primary Secondary Secondary/Rental Short-Term Rental Annual Rental Builders Risk Vacant Yeah Built: * Construction Type: * Froma Masonry Masonry Veneer Reinforced Masonry Fire Resistive Other Square Feet: * Number of Stories: * Select: 1 2 3 4 5 Basement: * No Yes Fire/Burglary Protection: (If NONE, Leave Blank) Monitored Burglar Alarm Monitored Fire Alarm Monitored Combo Alarm Distance to Hydrant: Distance to Fire Department: Other Water Source: 4. Update Information Roof Last Replaced: * Yes - Complete Yes - Partial Never / Not Sure Date of Replacement: MM DD YYYY Type of Plumbing: * Copper PVC Other If Other, Please Explain: Plumbing Last Replaced: * Yes - Complete Yes - Partial Never / Not Sure Date of Replacement: MM DD YYYY Electric Last Replaced: * Yes - Complete Yes - Partial No - Not Sure Date of Replacement: MM DD YYYY Heating / AC Last Replaced * Yes - Complete Yes - Partial Never / Not Sure Date of Replacement: MM DD YYYY 5. Mitigation Information Roof Type: * Gable Hip Flat Roofing Type: * Asphalt Shingles Architectural Shingles Clay Tile Cement Tile Metal Built-up Tar & Gravel Roof to Wall Connections: * Select ALL that apply. Toenails Clips Straps Date of Last Roof Inspection: MM DD YYYY Date of Last Mitigation Inspection: MM DD YYYY Hurricane Class A Shutters / Impact Glass: * Yes - Complete Yes - Partial No / Not Applicable Distance to Coastline/Waterways: * Florida Building Code: * Florida Properties Only. Yes No / Not Applicable 6. Additional Information Is There a Swimming Pool?: * Yes - Above Ground Yes - Inground No If YES, Select ALL that apply: Partially Fenced Fully Fenced Self-Locking Gate Diving Board Slide Maximum Depth: Have there been any bankruptcies? * Yes No Are there any animals on premises? * Yes No If YES, what type/breed? Is this a new home closing? * Yes No Have you had any claims within the past 5 years? * Yes No If YES, please list all details for the past 5 years: 7. Completed By Completed By: * By entering your name and clicking “Submit” you authorize East Coast Insurance Services, LLC and its affiliates to obtain insurance quotes on your behalf. First Name Last Name Today's Date * MM DD YYYY Thank you, someone from our office will reach out to you within the next business day.
